DOCSLIB.ORG

Capnography-Guided Intubation

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Capnography-Guided Intubation Capnography-Guided Intubation Vadim Pinskiy*, Neil Mori*, Harsh Shah*, Poonam Dudhat*, Glen Atlas# *Stevens Institute of Technology, Biomedical Engineering / Hoboken, NJ 07030 #Dept. of Anesthesiology, University of Medicine and Dentistry of New Jersey / Newark, NJ 07103 Abstract—The device uses capnography to guide intubation for more effective airway management. The carbon dioxide concentration is conveyed to the anesthesiologist through an audible signal, which is used to direct the endotracheal tube into the trachea. The process significantly speeds up procedure time in difficult airway cases while reducing the risk of improper tracheal tube placement. I. INTRODUCTION A. Background Intubation is a commonly performed medical procedure in which an artificial airway is established in a patient to provide proper gas exchange. It depends on the proper insertion of the endotracheal tube into the trachea instead of the esophagus. The placement of the endotracheal tube into the esophagus can lead to death, brain damage, insufflation of the stomach, II. PRELIMINARY STUDY damage to the epiglottis and does not correct the improper gas A preliminary study was performed on 12 patients by Dr. exchange. Improper placement of the endotracheal tube can be Atlas of the Anesthesiology Department at the University of difficult to detect and dramatically increases the intubation Medicine and Dentistry of New Jersey (UMDNJ) to confirm procedure time, often leading to complications. This problem feasibility of the design. The results showed that aspired CO2 is significantly magnified in difficult airway cases such as from tracheal intubations had a mean partial pressure of 23.25 those involving trauma or anatomical obstructions. mmHg with a standard deviation of 14.01 mmHg. Whereas Capnography is the monitoring of the concentration of esophageal intubations had a mean aspCO2 partial pressure of exhaled carbon dioxide in order to assess the physiologic 2.25 mmHg with a standard deviation of 2.06 mmHg (P = status of patients with acute respiratory problems. Up to now, 0.0036). The design immediately differentiated between the capnography was primarily used after the insertion of the trachea and the esophagus, resulting in a much faster endotracheal tube into the body to verify the position of the intubation. ET tube. Though effective, the process is quite time consuming, requiring the complete retraction and reinsertion III. DESIGN of the tube to change the location. The proposed device integrates a mainstream capnograph, a suction unit, and an audio circuit to obtain a direct B. Objective measurement of CO2, which is conveyed to the physician The purpose of the proposed device is to give physicians, through a dynamic audio circuit. For a standard 7.0 mm paramedics, and other airway management personnel the diameter endotracheal tube, an applied suction of 180 mmHg, ability to better manage difficult airway cases by using a turbulent airflow of 0.5 liters/second is generated with a capnography to guide the intubation. By providing real-time corresponding Reynolds number of 9,375, ensuring the CO2 feedback, the intubator will know immediately when the extraction of a sufficient gas sample quickly. The 180 mm Hg ET tube has entered the trachea (aspCO2 >5 mmHg) or the is critical to the proper functionality of the device. If the esophagus (aspCO2 <5 mmHg) and can take immediate action applied pressure is significantly greater then 180 mmHg, to correct the position of the tube. The primary application of physical damage to the lungs, trachea, pharynx or esophagus this device will be in difficult intubations, where the airway could result. If it is significantly lower, an insufficient sample pathway is obstructed by a large wound, fluids, tumor, or any will be extracted, resulting in a false reading. other major abnormality that prevents conventional intubation. The CO2 concentration of the extracted gas is measured by As a result, overall procedure time is shortened and the risk of a pre-calibrated infrared detector within the capnograph, this an esophageal intubation is greatly reduced, saving money, data is then relayed to the rest of the system through a voltage time, and lives. converter. The entire system will operate from a single 120 0-7803-9564-6/06/$20.00 ©2006 IEEE 101 AC power source and/or a single built-in battery, with an expected operating time of about 4 hours. The entire package will be portable, lightweight and rugged, ideal for hospital and pre-hospital settings. A. Measurement Mainstream capnographs function by using an infrared sensor to scan a small volume of gas, which is analyzed to determine the partial pressure of CO2. The capnograph selected for this design, unlike side-stream capnographs, had an external infrared detector which was positioned on the proximal end of the endotracheal tube, rather then inside the IV. TESTING main unit. Combined with a suction unit, this feature allows The preliminary testing of the device will be performed for real-time data acquisition. The vacuum pump of the unit is using laboratory means to test the response of the device to attached to the capnograph sensor and provides enough different levels of carbon dioxide at the distal end of the suction to deliver sufficient gas from the end of the ET tube to endotracheal tube. A two pump system will be used to obtain the proper mixture of oxygen and carbon dioxide, the flow of the capnograph sensor for a proper CO2 concentration measurement. The suction unit is small enough to be the mixture will be closely regulated to resemble that of the incorporated into the base of the capnograph. The low power trachea. consumption of the suction unit allows it to be incorporated After IRB approval at UMDNJ, the device will be tested into the main power supply of the capnograph during actual intubations to ensure the optimal operating conditions. A laptop-based data acquisition system will be B. The Audio Circuit used to track and record the performance and output of the To streamline the intubation process, an audio circuit was device. The laptop system will be operated independently of the device by a technician with no connection to the intubator. designed to correlate the concentration of aspired CO2 to the pitch of the projected sound. The change in pitch varies with Adjustments in the volume, quality and pitch sensitivity of the audio circuit will be adjusted based on the result of the study each incremental increase in the CO2 concentration; a difference of even 5 mmHg can easily be detected by an untrained professional. Guided by the pitch of the sound, the ACKNOWLEDGMENT intubator will be able to make real-time adjustments in the This project was greatly helped and would not be possible position of the ET tube as to increase the pitch and guide the without the assistance and guidance of Dr. Arthur Ritter and tube into the trachea. In future models, the volume and audio Professor Vikki Hazelwood of the Chemical, Biomedical and output can be adapted to accommodate most environmental Materials Department at Stevens Institute of Technology. Dr. conditions. Stuart Tewksbury of the Electrical and Computer Engineering Department was also a great inspiration and assisted the group C. Operation on countless of occasions with seemingly impossible circuit The device is operated by activating and calibrating the diagrams. We would also like to thank the staff of the capnograph using the built-in optical infrared standards. The Anesthesiology Department at the University of Medicine and suction unit is then connected to hollow stylet. A sterilized ET Dentistry of New Jersey – New Jersey Medical School. tube is then connected to the infrared detector of the capnograph. The stylet is then inserted into the proximal end REFERENCES of the ET tube, creating a closed path from the ET tube to the [1] G. Atlas, "Development, Characterization, and Initial infrared detector and the suction unit. When the intubator is Assessment of Capnography-Guided Intubation". Canadian ready to perform the procedure, the suction unit is activated Journal of Anesthesia, Volume 51(A44). June 2004. and the intubation is performed normally, except the intubator relies on the audio signal for any position adjustment. The [2] SD. Mentzelopoulos: "Capnography-guided nasotracheal audio circuit is calibrated to initially produce a low audible intubation of a patient with a difficult airway and unwanted respiratory depression". Anesthesia and Analgesia, Volume pitch correlating to a low CO2 reading of normal atmospheric air and assuring the intubator that the device is properly 87(3). September 1998. 734–736. working. Upon entering the trachea, the sound will change to [3] LH. Wolf: "Capnography during fiberoptic bronchoscopy a higher pitch in response to the increase in CO2 concentration, indicating that the ET tube is properly to verify tracheal intubation". Anesthesia and Analgesia, positioned and ready to be fixed in place. The stylet is then Volume 85(3). September 1997. 701–703 removed and discarded, along with the tubing of the suction unit. 102.
Load more

Recommended publications
  • Tracheal Intubation Following Traumatic Injury)
    CLINICAL MANAGEMENT ௡ UPDATE The Journal of TRAUMA Injury, Infection, and Critical Care Guidelines for Emergency Tracheal Intubation Immediately after Traumatic Injury C. Michael Dunham, MD, Robert D. Barraco, MD, David E. Clark, MD, Brian J. Daley, MD, Frank E. Davis III, MD, Michael A. Gibbs, MD, Thomas Knuth, MD, Peter B. Letarte, MD, Fred A. Luchette, MD, Laurel Omert, MD, Leonard J. Weireter, MD, and Charles E. Wiles III, MD for the EAST Practice Management Guidelines Work Group J Trauma. 2003;55:162–179. REFERRALS TO THE EAST WEB SITE and impaired laryngeal reflexes are nonhypercarbic hypox- Because of the large size of the guidelines, specific emia and aspiration, respectively. Airway obstruction can sections have been deleted from this article, but are available occur with cervical spine injury, severe cognitive impairment on the Eastern Association for the Surgery of Trauma (EAST) (Glasgow Coma Scale [GCS] score Յ 8), severe neck injury, Web site (www.east.org/trauma practice guidelines/Emergency severe maxillofacial injury, or smoke inhalation. Hypoventi- Tracheal Intubation Following Traumatic Injury). lation can be found with airway obstruction, cardiac arrest, severe cognitive impairment, or cervical spinal cord injury. I. STATEMENT OF THE PROBLEM Aspiration is likely to occur with cardiac arrest, severe cog- ypoxia and obstruction of the airway are linked to nitive impairment, or severe maxillofacial injury. A major preventable and potentially preventable acute trauma clinical concern with thoracic injury is the development of Hdeaths.1–4 There is substantial documentation that hyp- nonhypercarbic hypoxemia. Lung injury and nonhypercarbic oxia is common in severe brain injury and worsens neuro- hypoxemia are also potential sequelae of aspiration.
    [Show full text]
  • Tracheal Intubation
    //Tracheal Intubation http://www.expertconsultbook.com/expertconsult/b/book.do?m... Tracheal Intubation Technique As previously discussed, because of differences in anatomy, there are differences in techniques for intubating the trachea of infants and children compared with adults.[1–4,17–19,99,114,115] Because of the smaller dimensions of the pediatric airway there is increased risk of obstruction with trauma to the airway structures. A technique to be avoided is that in which the blade is advanced into the esophagus and then laryngeal visualization is achieved during withdrawal of the blade. This maneuver may result in laryngeal trauma when the tip of the blade scrapes the arytenoids and aryepiglottic folds. There are several approaches to exposing the glottis in infants with a Miller blade. One philosophy consists of advancing the laryngoscope blade under constant vision along the surface of the tongue, placing the tip of the blade directly in the vallecula and then using this location to pivot or rotate the blade to the right to sweep the tongue to the left and adequately lift the tongue to expose the glottic opening. This avoids trauma to the arytenoid cartilages. One can thus lift the base of the tongue, which in turn lifts the epiglottis, exposing the glottic opening. If this technique is unsuccessful, one may then directly lift the epiglottis with the tip of the blade (see Video Clip 12-1, Coming Soon). Another approach is to insert the Miller blade into the mouth at the right commissure over the lateral bicuspids/incisors (paraglossal approach). The blade is advanced down the right gutter of the mouth aiming the blade tip toward the midline while sweeping the tongue to the left.
    [Show full text]
  • Tracheotomy in Ventilated Patients with COVID19
    Tracheotomy in ventilated patients with COVID-19 Guidelines from the COVID-19 Tracheotomy Task Force, a Working Group of the Airway Safety Committee of the University of Pennsylvania Health System Tiffany N. Chao, MD1; Benjamin M. Braslow, MD2; Niels D. Martin, MD2; Ara A. Chalian, MD1; Joshua H. Atkins, MD PhD3; Andrew R. Haas, MD PhD4; Christopher H. Rassekh, MD1 1. Department of Otorhinolaryngology – Head and Neck Surgery, University of Pennsylvania, Philadelphia 2. Department of Surgery, University of Pennsylvania, Philadelphia 3. Department of Anesthesiology, University of Pennsylvania, Philadelphia 4. Division of Pulmonary, Allergy, and Critical Care, University of Pennsylvania, Philadelphia Background The novel coronavirus (COVID-19) global pandemic is characterized by rapid respiratory decompensation and subsequent need for endotracheal intubation and mechanical ventilation in severe cases1,2. Approximately 3-17% of hospitalized patients require invasive mechanical ventilation3-6. Current recommendations advocate for early intubation, with many also advocating the avoidance of non-invasive positive pressure ventilation such as high-flow nasal cannula, BiPAP, and bag-masking as they increase the risk of transmission through generation of aerosols7-9. Purpose Here we seek to determine whether there is a subset of ventilated COVID-19 patients for which tracheotomy may be indicated, while considering patient prognosis and the risks of transmission. Recommendations may not be appropriate for every institution and may change as the current situation evolves. The goal of these guidelines is to highlight specific considerations for patients with COVID-19 on an individual and population level. Any airway procedure increases the risk of exposure and transmission from patient to provider.
    [Show full text]
  • Tracheal Intubation in Critically Ill Patients
    Cabrini et al. Critical Care (2018) 22:6 https://doi.org/10.1186/s13054-017-1927-3 RESEARCH Open Access Tracheal intubation in critically ill patients: a comprehensive systematic review of randomized trials Luca Cabrini1,2, Giovanni Landoni1,2, Martina Baiardo Redaelli1, Omar Saleh1, Carmine D. Votta1, Evgeny Fominskiy1,3, Alessandro Putzu4, Cézar Daniel Snak de Souza5, Massimo Antonelli6, Rinaldo Bellomo7,8, Paolo Pelosi9* and Alberto Zangrillo1,2 Abstract Background: We performed a systematic review of randomized controlled studies evaluating any drug, technique or device aimed at improving the success rate or safety of tracheal intubation in the critically ill. Methods: We searched PubMed, BioMed Central, Embase and the Cochrane Central Register of Clinical Trials and references of retrieved articles. Finally, pertinent reviews were also scanned to detect further studies until May 2017. The following inclusion criteria were considered: tracheal intubation in adult critically ill patients; randomized controlled trial; study performed in Intensive Care Unit, Emergency Department or ordinary ward; and work published in the last 20 years. Exclusion criteria were pre-hospital or operating theatre settings and simulation- based studies. Two investigators selected studies for the final analysis. Extracted data included first author, publication year, characteristics of patients and clinical settings, intervention details, comparators and relevant outcomes. The risk of bias was assessed with the Cochrane Collaboration’s Risk of Bias tool. Results: We identified 22 trials on use of a pre-procedure check-list (1 study), pre-oxygenation or apneic oxygenation (6 studies), sedatives (3 studies), neuromuscular blocking agents (1 study), patient positioning (1 study), video laryngoscopy (9 studies), and post-intubation lung recruitment (1 study).
    [Show full text]
  • Expert Recommendations for Tracheal Intubation in Critically Ill Patients with Noval Coronavirus Disease 2019
    Chinese Medical Sciences Journal ISSN 1001-9294; CN 11-2752/R Published online 2020/2/27 doi:10.24920/003724 Expert Recommendations for Tracheal Intubation in Critically ill Patients with Noval Coronavirus Disease 2019 Mingzhang Zuo1, Yuguang Huang2*, Wuhua Ma3, Zhanggang Xue4, Jiaqiang Zhang5, Yahong Gong2, Lu Che2, Chinese Society of Anesthesiology Task Force on Airway Management 1 Department of Anesthesiology, Beijing Hospital, National Center of Gerontology; Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, 100730 China 2 Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730 China 3 Department of Anesthesiology, First Affiliated Hospital, Guangzhou University of Chinese Medicine, Guangzhou, 510405 China 4. Department of Anesthesiology, Zhongshan Hospital Fudan University, Shanghai, 200032 China 5. Department of Anesthesiology, Henan Provincial People's Hospital, Zhengzhou, 450003 China Abstract Coronavirus Disease 2019 (COVID-19), caused by a novel coronavirus (SARS-CoV-2), is a highly contagious disease. It firstly appeared in Wuhan, Hubei province of China in December 2019. During the next two months, it moved rapidly throughout China and spread to multiple countries through infected persons travelling by air. Most of the infected patients have mild symptoms including fever, fatigue and cough. But in severe cases, patients can progress rapidly and develop to the acute respiratory distress syndrome, septic shock, metabolic acidosis and coagulopathy. The new coronavirus was reported to spread via droplets, contact and natural aerosols from human-to-human. Therefore, high-risk aerosol-producing procedures such as endotracheal intubation may put the anesthesiologists at high risk of nosocomial infections. In fact, SARS-CoV-2 infection of anesthesiologists after endotracheal intubation for confirmed COVID-19 patients have been reported in hospitals in Wuhan.
    [Show full text]
  • Tracheal Intubation Intubação Traqueal
    0021-7557/07/83-02-Suppl/S83 Jornal de Pediatria Copyright © 2007 by Sociedade Brasileira de Pediatria ARTIGO DE REVISÃO Tracheal intubation Intubação traqueal Toshio Matsumoto1, Werther Brunow de Carvalho2 Resumo Abstract Objetivo: Revisar os conceitos atuais relacionados ao procedimento Objective: To review current concepts related to the procedure of de intubação traqueal na criança. tracheal intubation in children. Fontes dos dados: Seleção dos principais artigos nas bases de Sources: Relevant articles published from 1968 to 2006 were dados MEDLINE, LILACS e SciELO, utilizando as palavras-chave selected from the MEDLINE, LILACS and SciELO databases, using the intubation, tracheal intubation, child, rapid sequence intubation, keywords intubation, tracheal intubation, child, rapid sequence pediatric airway, durante o período de 1968 a 2006. intubation and pediatric airway. Síntese dos dados: O manuseio da via aérea na criança está Summary of the findings: Airway management in children is relacionado à sua fisiologia e anatomia, além de fatores específicos related to their physiology and anatomy, in addition to specific factors (condições patológicas inerentes, como malformações e condições (inherent pathological conditions, such as malformations or acquired adquiridas) que influenciam decisivamente no seu sucesso. As principais conditions) which have a decisive influence on success. Principal indicações são manter permeável a aérea e controlar a ventilação. A indications are in order to maintain the airway patent and to control laringoscopia e intubação traqueal determinam alterações ventilation. Laryngoscopy and tracheal intubation cause cardiovascular cardiovasculares e reatividade de vias aéreas. O uso de tubos com alterations and affect airway reactivity. The use of tubes with cuffs is not balonete não é proibitivo, desde que respeitado o tamanho adequado prohibited, as long as the correct size for the child is chosen.
    [Show full text]
  • Cardiopulmonary Resuscitation: to Intubate Or Not to Intubate
    ISSN 2379-4046 EMERGENCY MEDICINE Open Journal PUBLISHERS Editorial Cardiopulmonary Resuscitation: To Intubate or Not to Intubate Chien-Chang Lee, MD, ScD1*; Jon Wolfshohl, MD2; Eric H Chou, MD2 1Department of Emergency Medicine, National Taiwan University, Taipei 106, Taiwan 2Department of Emergency Medicine, John Peter Smith Hospital, Fort Worth, Texas, USA *Corresponding author Chien-Chang Lee, MD, ScD Department of Emergency Medicine, National Taiwan University Hospital, No. 7, Chung-Shan South Road, Taipei 100, Taiwan; Tel. +886-2-23123456 ext 62831; Fax. +886-2-23223150; E-mail: [email protected] Article information Received: July 27th, 2018; Accepted: August 20th, 2018; Published: August 20th, 2018 Cite this article Lee C-C, Wolfshohl J, Chou EH. Cardiopulmonary resuscitation: To intubate or not to intubate. Emerg Med Open J. 2018; 4(1): e1-e3. doi: 10.17140/EMOJ-4-e005 INTRODUCTION intrathoracic pressure resulting in depressed coronary perfusion pressure.4,5 Coronary perfusion pressure is the single most impor- ardiopulmonary resuscitation (CPR) is a “tug of war” between tant indicator for return of spontaneous circulation (ROSC). Low Clife and death. The most suspenseful and technically difficult coronary perfusion pressure (CPP) results in low ROSC rate. Giv- task in the resuscitation process is often endotracheal intubation. en the potential harm associated with tracheal intubation during re- However, the benefits of endotracheal intubation during CPR suscitation, a bold hypothesis was postulated: using a less invasive have been seriously challenged in recent literature.1 way of ventilation, such as bag-valve-mask ventilation or laryngeal mask ventilation, in place of tracheal intubation during CPR may POTENTIAL HARMS OF ENDOTRACHEAL INTUBATION reduce the interruption of chest compression and could improve DURING RESUSCITATION the CPR success rate.4-7 Establishment of an advanced airway to maintain gas exchange EVIDENCE FROM OBSERVATIONAL STUDIES and oxygenation has been viewed as an essential life-saving pro- cedure during resuscitation.
    [Show full text]
  • Elective Intubation
    Elective Intubation Charles G Durbin Jr MD FAARC, Christopher T Bell MD, and Ashley M Shilling MD Introduction Intubation: Perioperative Versus Outside the Operating Room Patient Examination and Airway Evaluation Predictors of a Difficult Airway Mouth Opening and Dentition Oral Cavity and Neck Mobility Evaluation Physiologic Risks of Intubation Environmental Assessment and Preparation Managing Airway Risks Outside the Operating Room Monitoring Intubation: Plans A, B, and C Preparing for Intubation Physical Considerations and Time-Out Denitrogenation or Preoxygenation Intubation Using Direct Laryngoscopy Initial Plan Confirmation of Tracheal Intubation Physiologic Changes and Management Strategies Alternative Airway Plans Postintubation Plans Transfer of Care After the Difficult Intubation: A Case Review Conclusions Endotracheal intubation is a commonly performed operating room (OR) procedure that provides safe delivery of anesthetic gases and airway protection during surgery. The most common intuba- tion technique in the perioperative environment is direct laryngoscopy with orotracheal tube in- sertion. Infrequently, difficulties that require an alternative intubation technique are encountered due to patient anatomy, equipment limitations, or patient pathophysiology. Careful patient evalu- ation, advanced planning, equipment preparation, system redundancy, use of checklists, familiarity with airway algorithms, and availability of additional help when needed during OR intubations have resulted in exceptional success and safety. Airway difficulties during intubation outside the controlled environment of the OR are more frequent and more serious. Translating the intubation processes practiced in the OR to intubations outside the perioperative setting should improve patient safety. This paper considers each step in the OR intubation process in detail and proposes ways of incorporating perioperative procedures into intubations outside the OR.
    [Show full text]
  • Optical Devices in Tracheal Intubation—State of the Art in 2020
    diagnostics Review Optical Devices in Tracheal Intubation—State of the Art in 2020 Jan Matek 1,2, Frantisek Kolek 3, Olga Klementova 4, Pavel Michalek 5,6 and Tomas Vymazal 3,* 1 1st Department of Surgery—Department of Abdominal, Thoracic Surgery and Traumatology, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, 12800 Prague, Czech Republic; [email protected] 2 Medical Faculty, Masaryk University, 62500 Brno, Czech Republic 3 Department of Anesthesiology and Intensive Medicine, University Hospital Motol, V Úvalu 84, 15000 Praha, Czech Republic; [email protected] 4 Department of Anesthesiology and Intensive Medicine, University Hospital Olomouc, I.P. Pavlova 185, Nová Ulice, 77900 Olomouc, Czech Republic; [email protected] 5 Department of Anesthesiology and Intensive Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital, U Nemocnice 499/2, 12808 Praha, Czech Republic; [email protected] 6 Department of Anaesthesia, Antrim Area Hospital, Antrim BT41 2RL, UK * Correspondence: [email protected]; Tel.: +420-606-413-489 Abstract: The review article is focused on developments in optical devices, other than laryngoscopes, in airway management and tracheal intubation. It brings information on advantages and limita- tions in their use, compares different devices, and summarizes benefits in various clinical settings. Supraglottic airway devices may be used as a conduit for fiberscope-guided tracheal intubation mainly as a rescue plan in the scenario of difficult or failed laryngoscopy. Some of these devices offer the possibility of direct endotracheal tube placement. Hybrid devices combine the features of two different intubating tools.
    [Show full text]
  • Tracheal Intubation Awake Or Under Anesthesia for Potential Difficult Airway: Look Before You Leap Fu-Shan Xue Capital Medical University
    Washington University School of Medicine Digital Commons@Becker Open Access Publications 2018 Tracheal intubation awake or under anesthesia for potential difficult airway: Look before you leap Fu-Shan Xue Capital Medical University Qian-Jin Liu Washington University School of Medicine in St. Louis Follow this and additional works at: https://digitalcommons.wustl.edu/open_access_pubs Recommended Citation Xue, Fu-Shan and Liu, Qian-Jin, ,"Tracheal intubation awake or under anesthesia for potential difficult airway: Look before you leap." Chinese Medical Journal.131,6. (2018). https://digitalcommons.wustl.edu/open_access_pubs/6692 This Open Access Publication is brought to you for free and open access by Digital Commons@Becker. It has been accepted for inclusion in Open Access Publications by an authorized administrator of Digital Commons@Becker. For more information, please contact [email protected]. [Downloaded free from http://www.cmj.org on Monday, April 2, 2018, IP: 128.252.174.220] Comments Tracheal Intubation Awake or Under Anesthesia for Potential Difficult Airway: Look Before You Leap Fu‑Shan Xue1, Qian‑Jin Liu2 1Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China 2Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA Securing a patent airway remains a pivotal point in clinical and third most frequent causal and contributory factors anesthesia, while failure to establish airway in anesthetized (next to patient factors; 77%), respectively. Furthermore, patients can cause severe outcomes in a few minutes.[1] deficiencies in airway assessment, underutilization of awake According to the closed claims analysis conducted by the tracheal intubation, inappropriate use of supraglottic airway American Society of Anesthesiologists, a leading cause of devices, and evidence of poor airway management planning anesthesia‑related patient injury is the inability to intubate were also noted.[4] These findings indicate that current the trachea and secure the airway.
    [Show full text]
  • This Procedure Includes the Following: • Endotracheal Intubation (Plus Use of Supraglottic Airway Laryngopharyngeal Tube (S.A
    ADVANCED AIRWAY PROCEDURES This procedure includes the following: Endotracheal intubation (plus use of Supraglottic Airway Laryngopharyngeal Tube (S.A.L.T. device), gum elastic bougie assisted tracheal intubation, video laryngoscopy) Non-Visualized Airways (Dual lumen airway, King LT-D™ Airway, Laryngeal Mask Airway (LMA)) Cricothyroidotomy – needle and surgical GENERAL CONSIDERATIONS Rescuers must be aware of the risks and benefits of advanced airway management techniques. In cases of cardiac arrest the insertion of an advanced airway may require interruption of chest compressions for many seconds, the rescuer should weigh the need for compressions against the need for insertion of an advanced airway. Rescuers may defer insertion of an advanced airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates return of spontaneous circulation. Providers should have a second (back-up) strategy for airway management and ventilation if they are unable to establish the first-choice airway adjunct. Bag-mask ventilation may provide that back-up strategy. ENDOTRACHEAL INTUBATION A. Indications for emergency endotracheal intubation are: 1. Inability of the rescuer to adequately ventilate the patient with a bag-mask device 2. The absence of airway protective reflexes (coma and cardiac arrest) B. In most case, endotracheal intubation provides definite control of the airway. Its purposes include: 1. Actively ventilating the patient 2. Delivering high concentrations of oxygen 3. Suctioning secretions and maintaining airway patency 4. Preventing aspiration of gastric contents, upper airway secretions or blood 5. Prevented gastric distention due to assisted ventilations 6. Administering positive pressure when extra fluid is present in alveoli 7. Administering medications during resuscitation for absorption through lungs as a last resort C.
    [Show full text]
  • Airway Management
    AIRWAY MANAGEMENT Angkana Lurngnateetape, MD. Department of Anesthesiology Siriraj Hospital Perhaps the most important responsibility of the anesthesiologist is “management of the patient’s airway” Miller RD’s Anesthesia 2000 Barash PG, Cullen BF, Stoelting RK’s Clinical Anesthesia 2001 What should we know about “airway management”? ● Airway anatomy and function ● Evaluation of airway ● Clinical management of the airway - Maintenance and ventilation - Intubation and extubation - Difficult airway management Airway anatomy The term “airway” refers to the upper airway, consisting of ● Nasal and oral cavities ● Pharynx ● Larynx ● Trachea ● Principle bronchi Anatomy of upper airway Larynx in laryngoscopic view Nerves V1 V2 V3 IX Vagus nerve • Superior laryngeal n – External br (Motor) • cricothyroid m SL – Internal br (Sensory) • area above cord • Recurrent laryngeal n - Motor br • intrinsic m RL – Sensory br • area below cord Evaluation of the airway ● History ● Physical examination ● Special investigation Evaluation of the airway “History” ● Previous history of difficult airway ● Airway-related untoward events ● Airway-related symptoms/diseases Evaluation of the airway Physical examination ● Ease of open airway and maintenance ● Ease of tracheal intubation ● Teeth ● Neck movement ● Intubation hazards ● Signs of airway distress Evaluation of the airway Anatomic characteristics associated with difficult airway management ● Short muscular neck ● Receding mandible ● Protruding maxillary incisors ● Long high-arched palate ● Inability to visualize
    [Show full text]